Primary epidermoid cysts of the mastoid: clinical and treatment implications.

Epidermoid cysts of the temporal bone are extremely rare and such lesions arising in isolation within the mastoid bone have never been reported in literature. We report and describe the first two unique cases of primary epidermoid cysts arising in the mastoid bone. Of the two cases, one presented with progressive headache and imbalance and the other with unilateral hearing loss and tinnitus. Both cases needed CT and MRI scans and needed surgical management. We review the clinical presentations, histology, pathogenesis, radiological findings and management of these challenging cases. The diagnosis of an epidermoid cyst is based on clinical presentation, physical examination and especially the radiological, histological and intraoperative findings. Total removal of the lesion along with its capsule is recommended to prevent recurrence and to allow for a good long-term prognosis.

Interventions for the prevention of postoperative ear discharge after insertion of ventilation tubes (grommets) in children.

BACKGROUND: Grommets are frequently inserted in children's ears for acute otitis media and otitis media with effusion. A common complication is postoperative ear discharge (otorrhoea). A wide range of treatments are used to prevent the discharge, but there is no consensus on whether or not intervention is necessary nor which is the most effective intervention. OBJECTIVES: To assess the effectiveness of prophylactic interventions, both topical and systemic, in reducing the incidence of otorrhoea following the surgical insertion of grommets in children. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 3 July 2012. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared the efficacy of prophylactic interventions against placebo/control and/or with other prophylactic interventions for postoperative otorrhoea in children. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility and risk of bias, and extracted data. The outcome data were dichotomous for all the included trials. We calculated individual and pooled risk ratios (RR) using the Mantel-Haenszel fixed-effect method. We also calculated the numbers needed to treat to benefit (NNTB). MAIN RESULTS: We found 15 eligible RCTs (2476 children, aged from four months to 17 years). We graded seven RCTs as being at a low risk of bias (n = 926 children) and for an eighth RCT we also graded two of the arms as being at a low risk of bias. We graded the other seven trials as being at a high risk of bias.For a single application at surgery, there was evidence from two low risk of bias trials that at two weeks postoperatively the risk of otorrhoea was reduced by multiple saline washouts (from 30% to 16%; RR 0.52, 95% confidence interval (CI) 0.27 to 1.00; NNTB 7; one RCT; 140 children) and antibiotic/steroid ear drops (from 9% to 1%; RR 0.13, 95% CI 0.03 to 0.57; NNTB 13; one RCT; 322 ears). A meta-analysis of two low risk of bias trials (222 ears) failed to find an effect of a single application of antibiotic/steroid ear drops at four to six weeks postoperatively.For a prolonged application of an intervention, there was evidence from four low risk of bias trials that the risk of otorrhoea was reduced two weeks postoperatively by antibiotic ear drops (from 15% to 8%; RR 0.54, 95% CI 0.30 to 0.97; NNTB 15; one RCT; 372 children), antibiotic/steroid ear drops (from 39% to 5%; RR 0.13, 95% CI 0.05 to 0.31; NNTB 3; one RCT; 200 children), aminoglycoside/steroid ear drops (from 15% to 5%; RR 0.37, 95% CI 0.18 to 0.74; NNTB 11; one RCT; 356 children) or oral antibacterial agents/steroids (from 39% to 5%; RR 0.13, 95% CI 0.03 to 0.51; NNTB 3; one RCT; 77 children).Only one trial assessed the secondary outcome of ototoxicity, but no effect was found. There were no trials that assessed quality of life. AUTHORS' CONCLUSIONS: Our review found that each of the following were effective at reducing the rate of otorrhoea up to two weeks following surgery: (1) multiple saline washouts at surgery, (2) a single application of topical antibiotic/steroid drops at surgery, (3) a prolonged application of topical drops (namely antibiotic ear drops, antibiotic/steroid eardrops or aminoglycoside/steroid ear drops) and (4) a prolonged application of oral antibacterial agents/steroids. However, the rate of otorrhoea between RCTs varied greatly and the higher the rates of otorrhoea within a RCT, the smaller the NNTB for therapy.We conclude that if a surgeon has a high rate of postoperative otorrhoea in children then either saline irrigation or antibiotic ear drops at the time of surgery would significantly reduce that rate. If topical drops are chosen, it is suggested that to reduce the cost and potential for ototoxic damage this be a single application at the time of surgery and not prolonged thereafter.

Hemoglobin monitoring in head and neck cancer patients undergoing radiotherapy.

OBJECTIVES: Anemia is a well-recognized factor for local recurrence and decreased survival in cancer patients undergoing radiotherapy. Additionally, lower hemoglobin (Hb) levels have a negative impact on radiotherapy efficacy and response rates. The objective of this audit was to investigate how frequently Hb levels were observed in head and neck cancer patients receiving radiotherapy within a multidisciplinary team setting. METHODS: We performed a retrospective first-cycle audit in a university hospital in Glasgow that is a tertiary referral center for head and neck cancer. Included were 78 patients with head and neck cancer who were undergoing radiotherapy. Online laboratory services and clinical case sheets were checked for each patient to monitor the frequency of observation of Hb levels before, during, and after radiotherapy. RESULTS: Of these 78 patients, only 49 had their Hb level checked before radiotherapy treatment, only 9 during radiotherapy, and only 27 after completion of radiotherapy treatment (p < 0.0001). Of the 49 patients with preradiotherapy Hb levels available, 24% were found to be anemic; none of these patients had their Hb monitored during radiotherapy, and only 4 had Hb levels recorded after completion of treatment. CONCLUSIONS: This audit has highlighted that despite evidence emphasizing that anemia in cancer is an independent prognostic factor for recurrence, there is no formal protocol for Hb monitoring in head and neck cancer patients undergoing radiotherapy. The audit has also demonstrated that Hb monitoring is infrequently performed and that subsequent observation of the Hb level is suboptimal.

Gamma tubulin: a promising indicator of recurrence in squamous cell carcinoma of the larynx.

OBJECTIVE: Centrosome amplification as detected by gamma tubulin (GT) immunostaining is associated with genetic instability and tumor aggressiveness. We assessed GT for its ability to predict recurrence of squamous cell carcinoma of the larynx (SCCL). STUDY DESIGN: Case series with chart review. MATERIALS AND METHODS: Five micron sections of 35 archival SCCL samples were subjected to antigen retrieval and immunostaining with antibody to GT. The keratin antibody CK5 served as a positive control for antigen retrieval, and tonsillar tissue was used as a negative control. RESULTS: Of the 35 tumors analyzed, 22 were associated with recurrence(R) and 13 were not (NR). Fourteen of the 22 R tumors, but 0 of 13 of the NR tumours had a GT staining score of 2+ or 3+ (P < 0.0002). GT was also related to recurrence in node-negative tumors (P < 0.006) but was unrelated to T stage (P = 0.726). CONCLUSIONS: GT staining appears to be a better predictor of tumor recurrence than T stage and also predicts recurrence in N0 tumors.

Life threatening hemorrhage from osteoradionecrosis of the ribs and clavicle.

Osteoradionecrosis (ORN) is a familiar complication of radiotherapy. ORN of the clavicle and ribs is well documented after radiation therapy for breast and pulmonary malignancy. ORN of the clavicle after radiation therapy to the neck is very rare. We report the first case in which both clavicles and first ribs underwent ORN 14 years after neck irradiation and surgery for laryngeal malignancy. The presentation was atypical; erosion of the right internal mammary artery causing life-threatening hemorrhage. Otolaryngologists should be aware that ORN can occur at an unusual site and can have an atypical presentation.

Lemierre syndrome: two cases and a review.

OBJECTIVES: Lemierre syndrome is usually caused by an acute oropharyngeal infection in previously healthy young adults, resulting in thrombophlebitis of the internal jugular vein, leading to metastatic septic embolization and bacteraemia. The usual organism is Fusobacterium necrophorum. Lemierre syndrome, not so long ago labeled as the "forgotten disease," is on the rise. Today with increasing antibiotic-resistant organisms, and decreasing awareness of the syndrome, subsequent re-emergence of this "forgotten disease" is becoming more common in clinical settings. Lemierre syndrome has significant morbidity. Cranial nerve complications associated with the condition have been increasingly diagnosed in the last few years. Looking back at literature on Lemierre syndrome, there have been review articles in medical and microbiology journals but rarely in otolaryngology journals. By presenting our cases we demonstrate the diverse presentations and severity of the illness. METHODS: A review of the literature and a case report on two cases seen in our institution in the last year are presented. Each of these had varied presentations and neurologic complications-one developed 9th to 12th cranial nerve palsies and Horner syndrome, which have not been described in previous literature, and the other developed polyneuropathy and a frontal lobe infarct among other multisystem complications. CONCLUSIONS: Diagnosis of Lemierre syndrome is not always straightforward as clinical features are variable and blood cultures are often negative. Awareness of the syndrome and a high degree of suspicion are needed.

Sinonasal glomangiopericytoma: Is anything new?

More than 100 cases of sinonasal hemangiopericytoma have been reported in the literature, but only a handful of cases of nasal glomangiopericytoma. In this article, we report a case of a nasal glomangiopericytoma that was treated with endonasal surgical excision. We also attempt to clarify the confusion that attends to the nomenclature surrounding the terms glomangiopericytoma and hemangiopericytoma, which are often used interchangeably. Although glomangiopericytomas are histologically similar to sinonasal hemangiopericytomas, they sometimes behave in a different clinical manner. To further enhance our understanding of nasal glomangiopericytomas, more cases need to be reported. This may improve our ability to establish specific treatment modalities for this type of neoplasm and to predict clinical outcomes.

Ménière's Syndrome or Disease: Time Trends in Management and Quality of Evidence Over the Last Two Decades.

OBJECTIVE: To evaluate the evidence and trends in published literature on the treatment of Ménière's syndrome or disease (MS/D) by comparing studies published in the last two decades. DATA SOURCES: A literature search was performed on AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE, CENTRAL and Cochrane Ear, Nose and Throat disorders groups trials register using a combination of MeSH. The date of last search was October 2014. STUDY SELECTION AND DATA EXTRACTION: Two hundred five studies (104 in decade I and 101 in decade II) were evaluated to report trends in the management of this condition, the differing levels of evidence published for each treatment modality, evaluate whether the guidelines published by the AAOHNS-Committee on Hearing and Equilibrium had been correctly employed, and whether the randomized controlled trials (RCTs) were compliant with the CONSORT guidelines. RESULTS: The number of published RCTs almost tripled from decade I (1994-2003) to decade II (2004-2103). There was a significant decline in the use of surgical intervention (p = 0.013); however, the number of studies involving the use of intratympanic injection remained largely unchanged. There was a shift in the level of evidence in published studies; studies with level 1 evidence tripled from decade I to II (4.8 to 17.8%, respectively) (p = 0.03); however, compliance with the AAOHNS-CHE criteria for reporting treatment outcomes and the CONSORT checklist was still poor. CONCLUSION: Although the evidence base on published literature on MS/D has improved over the last decade with an increase in emphasis on RCTs and quality of life (QoL) studies, a significant number of studies failed to follow AAOHNS-CHE criteria for reporting treatment outcome and the CONSORT criteria for reporting RCTs.

Paraganglioma of the skull base presenting as nasal polyps.

The authors report a case of paraganglioma of the skull base presenting as nasal polyps. A 29-year-old patient presented with epistaxis and was found to have nasal polyps. The patient underwent a nasal polypectomy. After pathology showed an unusual appearance, the mass was subsequently excised endoscopically using radiofrequency coblation, and it was found to be originating from the skull base. The diagnosis was made using a combination of clinical findings, radiology, and histopathology examination. It is important to consider paraganglioma in the differential diagnosis of unusual tumors of the nose and skull base.

Early experience of radio frequency coblation in the management of intranasal and sinus tumors.

The purpose of this study was to evaluate the safety and efficacy of the use of radiofrequency coblation for endoscopic resection of intranasal and sinus tumors. A review was conducted of 15 adult patients with intranasal and or sinus tumors endoscopically treated with radio frequency coblation between November 2008 and November 2010 at St. John's Hospital at Livingston, a tertiary referral center that covers otolaryngology services for the southeast of Scotland. Fifteen patients with intranasal and sinus tumors were treated with transnasal endoscopic resection using radiofrequency coblation. The tumors included inverted papilloma (seven), paraganglioma (one), glomangiopericytoma (one), capillary hemangioma (one), hemangiopericytoma (one), juvenile angiofibroma (one), juvenile ossifying fibroma (one), oncocytic adenoma (one), and transitional cell carcinoma (one). We found that radiofrequency coblation is a useful and safe tool associated with minimal blood loss (<200 mL to 600 mL) in the resection of these tumors, and the average operating time was 1.67 hours. Radio frequency is a rapidly evolving technique and in the future will have an increasing role to play in the endoscopic resection of intranasal and sinus tumors.

Unintended benefits of immunosupression on autoimmune disease due to chemoradiation therapy for head and neck cancer.

The immune system is an important factor in the host's defenses against cancer. Immunosupression by radiation and/or chemotherapy is often associated with systemic and hematologic complications, opportunistic infections, and the development of malignancies, but immunosupression can also have beneficial effects, which are sometimes incidental. We report 2 patients with autoimmune diseases where immunosupression had beneficial effects. The first case is about a patient with carcinoma of the tonsil, with severe rheumatoid arthritis, who was treated with chemoradiation, which resulted in remission of his arthritis. The second case is about a patient with severe atopic eczema who was on long-term treatment with psoralen and ultraviolet A radiation and azathioprine; the patient developed metastatic carcinoma of the lip, which was treated with surgery and radiation that resulted in complete remission of his eczema.